Patient Interview Template
IDENTIFYING INFORMATION Age: Sex: Race: Marital status: Employment status: CHIEF COMPLAINT/MAJOR LIFETIME PROBLEM (use patient’s own words)
HPI (include pertinent negatives, current psychotropic medications)
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PAST PSYCHIATRIC HISTORY Initial symptoms/symptoms not currently of concern:
Prior treatment and response to treatment:
Other psychiatric disorders that have resolved:
FOCUSED MEDICAL HISTORY Current illnesses:
Medications:
Allergies:
Prior serious illness or surgeries:
Reproductive history:
Pertinent negatives:
SUBSTANCE USE HISTORY (pattern of use, longest periods of abstinence, use of self-help or professional resources) Drugs: Alcohol: Cigarettes: FAMILY PSYCHIATRY HISTORY (first- and second-degree relatives) Mental illnesses: Suicides: Substance abuse:
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SOCIAL/DEVELOPMENTAL HISTORY Family of origin: - Members: Ethnic background: Social background:
Relationship between parents: Parents’ relationship to children:
Major life events (moves, divorces, deaths):
School history:
Early friendships:
Adolescent behavior:
Intimate relationships:
College/military history:
Adult work history:
Adult relationships:
Marriages:
Relationships with children:
Current social situation:
Current job stability:
Financial difficulties/resources:
Supportive/problematic relationships:
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MENTAL STATUS EXAMINATION (include pertinent negatives) Appearance - Dress: Grooming: Weight: Motor behavior: Eye contact:
Level of consciousness: Attitude toward interview: Speech: Thought process: Affect: Mood: Perceptions: - Hallucinations: Illusions:
Thought Content: - Delusions: Ideas of reference: Preoccupations (main themes/concerns):
Suicidal/assaultive thought, plans, intentions: Formal cognitive tests: - Orientation: Attention: Concentration: Registration and short-term memory: Calculations: Abstraction: Fund of knowledge: Vocabulary:
Insight (into source of symptoms or into personal motivations, qualities): Tested judgment, personal judgment:
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MULTIAXIAL DIAGNOSIS Axis I: Main provisional diagnoses, diagnoses to “consider also”
Axis II: Possible maladaptive personality traits
Axis III: Current medical problems, medical problems contributing to current condition
Axis IV: Main stressors
Axis V: Global assessment of function (use published scale in DSM-IV)
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